Sunday, May 07, 2017

Negotiated Rates: What No One Talks About in Health Care Legislation


Last week, the House of Representatives passed legislation for the American Health Care Act, the first step in repealing the Affordable Care Act, or as some would call it, Trumpcare versus Obamacare.  The American Psychiatric Association and the American Medical Association (and many other medical societies) oppose the new legislation.  An enormous concern is that the new legislation won't require insurance companies to cover preexisting conditions, or require coverage for mental health treatment or prenatal/maternity care.  Over the coming years, the new legislation is predicted to leave 24 million more Americans without health insurance coverage.

There are many criticisms of the ACA, one being that it forces people to pay for care for illnesses that they don't have and many will never get.  I'm not sure why no one talks about policies where people can opt out of having coverage for cancer. Cancer is a very expensive disease, and not everyone gets it.  If you believe you're at low risk, why should you have to foot the bill for someone's lung cancer any more than you should have to foot the bill for your neighbor's episode of depression?  

Sarcasm aside, I wanted to talk about something that I don't see discussed anywhere.  One huge and accurate criticism of the ACA is that premiums are high and deductibles are high.  I'm not a fan, and it leaves people angry that they pay so much for health insurance and get so little out of it.  But there is something missing in this discussion: if a person has health insurance and they see a doctor, have a procedure, have a lab test done, or get a scan, then the cost to the patient is the cost that has been negotiated by the the health insurance company, and it's remarkably lower than the cost to that a person with no health insurance. The craziness of our current health care system is that the people who can most afford to pay for their care are the ones who pay the least.  So the high deductible may mean that a person pays for his own care, and only sees the benefit of being insured if there is a catastrophic illness, but it also means that while paying for that high-deductible care, out-of-pocket care non-catastrophic costs much less than the uninsured person pays.  It's a crazy system where the poor subsidize the rich -- if a hospital will much lower fees from an insured person, why not accept those same lower fees from someone who doesn't have insurance?   Does requiring people to purchase health insurance even out in the end?  Not for those who are healthy: it leaves the "well" subsidizing the "sick," which in my opinion is better than the "poor" subsidizing the "rich." 

No answers here.  I don't believe that health insurance should be allowed to exclude those with pre-existing conditions: it dissuades people from getting care for fear of acquiring this label, and it provides a service that only the healthy or financially comfortable can afford.  It's not even clear to me what defines a pre-existing condition: 23% of women in their 40's take an SSRI, do they all have a preexisting condition?  If you told your doctor you were struggling with stress during a difficult time and she jotted "anxiety" on as a diagnosis once, does that mean you have a condition?

 For catastrophic conditions, the taxpayer ends up with the bill anyway: before the ACA, if your car crashed or you were diagnosed with cancer or you ended up in the ER in a psychotic state, you were treated. Then you went bankrupt and got Medicaid; this didn't help anyone.  If we can pick and choose, like playing Russian roulette with our health, well, I might not want to pay for your prostate cancer treatments any more than you wanted to pay for my maternity benefits, and I've never smoked, so I may be willing to role the dice on not getting lung cancer. Insurance is about diversifying risk. Mental health, addiction, and maternity services need to be part of the deal and you shouldn't get to pick and choose what health conditions you think you might get.  

We need a mechanism beyond employer-based health insurance to care for those who are self-employed or who work at part-time or contractual jobs; we shouldn't have a situation again where someone in a family must work for an institution large enough to provide health benefits.  Our young people today are not all poised to go straight from college to a job with health insurance; continuing family coverage until age 26 for this mostly health group of young people makes sense.  For those in higher income brackets, it may make sense to charge more for family coverage for each adult child over age 21, but I've not seen that option mentioned anywhere.  Finally,  and perhaps most importantly, Trumpcare decreases funding to Medicaid: it denies the poorest among us health insurance, and as Mr. Trump might tweet: BAD! I can't see a way that leaving those who can least afford care uncovered would be cost-effective.

In all fairness, the administrative hassles of the ACA have not been good: they've diverted doctor time away from patient care and we have physician shortages. But perhaps the answer is to fix the troubled legislation that we have, not to start over. Personally, I think we should look to other countries and see if we can figure out what we're doing wrong: the US has the highest health care costs, and our results don't support this, we have the 46th longest life-span.  Not so good for the greatest country on earth.

12 comments:

Joel Hassman said...

I have to say, this is why the Democrat's attitude that inherently the pain is minimal is just disingenuous at least, and I think it equally dishonest. Without going into specifics, I have seen my premium rise over 50% in the past 3 years, and my deductible is now over $10,000 for the family and over $5K for one person each. Yes, I earn a decent income, but, my health care expenses last year were over 15% of my income for the year, and I was not hospitalized nor diagnosed with a serious chronic condition, nor anyone else in my family.

So, having insurance coverage has SOME benefits, but it equally has detriments as well, and I defy you or any other honest person accepting the need to weigh the benefit/detriment profile to say basically flipping a coin to make a decision is a wise option. Not that I have any faith nor respect the Republicans can or will do better, but, isn't it time to stop letting politicians set health care policies???

I would hope you will agree with this basic premise I go by: people who make decisions/policies/laws that affect others, and those who make such demands are not affected by the boundaries nor make any effort to discuss with those affected by such boundaries before implementing them are bad decisions/policies/laws. Being detached, unconcerned, or just plainly wanting control are poor traits for those who have power, influence, and seen as leaders.

And in my opinion that is what you have in D.C., irregardless of party. Just remember one thing, if Obamacare was such a wonderful legislative initiative, then how did the Democrats lose so much in positions of representation not only federally, but in states and local positions as well!?

Helping some while screwing others is not good policy, but just partisan agenda. And frankly, you should know that now if you do not already. Physicians should be advocating for returning the health care process between patient and provider, not just persisting in letting it be triangulated and not just lamely or helplessly just echoing "that's just the way it is".

Cue Hornsby's response, "ah, but don't you believe them"...

David J. Littleboy said...

FWIW, the "pre-existing conditions" thing is unique to the US. No other industrialized country asks you your health history when determining eligibility or cost. Everywhere else in the world assumes that the purpose of health insurance is to pay for health care. Also, there's pretty much no such thing as medical bankruptcy anywhere else in the industrialized world.

Basically, Obamacare brought the US largely into line with modern advanced rich country standards. The Republicans want to go back.

The Republicans in the US think that if you are rich and healthy, it's because you are doing things right, and deserve their support. And shouldn't have to pay to support people who are obviously doing something wrong and don't deserve to be supported. They really think that. Trumpcare gives a tax break (compared to Obamacare) of over 7 million dollars per year to each and every one of the 400 richest families in the US. So that they don't have to pay for poor folks (and Jimmie Fallon's!) medical care.

We enacted a tax that saves a _lot_ of lives every year (providing health insurance, on average, prevents one unnecessary death per 850 people covered per year (funny thing: doctors are good at their jobs!)), and the Republicans want to rescind that tax and let people die. They really do.

David J. Littleboy said...

I hope I'm not wearing out my welcome, but Japan (where I'm a long-term resident) beats out the US something fierce in three areas: infant and maternal mortality and morbidity (Japan is close to the best in the world, the US is at third world levels), life expectancy at birth (although life expectancy at 65 is closer (sigh: I'm 65)), and cost (about 1/3 the cost per person).

I think that the reason Japan does well on the first two is that there are very few people left out. Being poor or a minority in the US is, it seems, way worse than being poor or a minority in Japan (not that it's nice being poor or a minority here, but there's a basic idea that everyone Japanese is Japanese and it mostly works that way). Japan has long (since the 1950s, thanks in part to the US occupation) had a more equitable distribution of wealth than the US, and although Japan is getting worse in that aspect, so is the US. But Japan largely succeeds in providing everyone with medical care. So I believe that doubling the minimum wage and recognizing that Black (and poor and other minority) lives really do matter would do more for those two aspects than futzing with the medical system.

On costs, Japan is basically a single-payer system with draconian price controls. Doctors make much less money in Japan than the US (although it's just as desirable a profession, and medical school is just as hard to get into). The current situation in the US, where it's the insurance companies that try to control costs and the medical providers that keep merging into larger and larger organizations to fight the insurance companies simply isn't working. So the US needs some sort of government imposed price controls or limits; i.e. more regulation. Probably not a lot more: we can afford to pay more than Japan does, we're a rich country. But radical differences in charges and price gouging need to be gotten under control. And the US needs to be able to negotiate drug prices with big pharma.

Hey, welcome back! You'd been quiet for a bit.

therapyfirst said...

I think this below link about what is happening with Obamacare still in place since the Republican legislation has not been passed yet, much less been debated by the Senate regarding changes to send back to the House, shows what the law is doing, and it mentions Maryland as example:

http://www.washingtonexaminer.com/walls-fall-in-on-obamacare/article/2622868

Two point there that need to be flagrantly highlighted:

1. People are not "owed" to be bailed out and others pay for the alleged neglected indefinitely, it's time for people to figuratively learn how to fish. Sorry, never signed any contract I have to save the world, it's a choice, not a demand.

2. Making the cost of health care so prohibitive will have consequences on those who can't afford it, ironically making those who were being responsible in staying active in health care behaviors to stop and then be at risk. Sorry, this law was at least partially a class divisive move by Obama and the Democrats, it was a "middle class gets screwed" agenda because they don't automatically vote Democrat.

So, we can read a developing thread here of those who benefit from the law, for reasons I doubt transparency will be complete, and those who are harmed, who seem to be more direct and to the point. But, as I said earlier, you really want to flip a coin to decide if a choice should be made?

Oh, and by the way, those using other countries' health care systems as example of how that works so well, there are two flaws to using them as comparisons to what is devolving here now:

1. Those systems outside America have been in place for over 2 generations of time now, so people are just brow beaten into that is how it is, and not knowing there is a better way to handle health care doesn't infer their experience trumps ours.

2. In somewhat relation to one, doctors who don't know there are options to have real independence and autonomy how to practice health care responsibly and per true clinical care choices, again are at least ignorant of realities outside their borders. Our health care system was better than most countries, patients by in large had more options and choices, these other countries just found ways to adapt to survive and give illusions they are comparable.

Let's end with the painful truth Obamacare has wrought on the country:

http://www.cnsnews.com/commentary/hans-bader/under-obamacare-death-rates-rise-and-life-expectancy-falls-2015

Let's read from the Obamacare proponents how that shows political intrusions into health care have improved our lives.

Let the silence or deflection commence...

Joel Hassman, MD

David J. Littleboy said...

"1. Those systems outside America have been in place for over 2 generations of time now, so people are just brow beaten into that is how it is, and not knowing there is a better way to handle health care doesn't infer their experience trumps ours."

Universal health care is a truly beautiful thing: you get sick or hurt, you go to the doc, you get treated, you get charged a pittance, you go home. I was hospitalized for 5 days for emergency surgery. They charged me US$2,000 and refunded half of it a few months later (and apologized for it taking so long). Many Americans just don't get it how incredibly cruel the US system is.

I've in both systems for 30 years (each) now, and I assure you, the US system is completely and totally insane. What is it about "everyone has full access to affordable and good medical care (including dental!) with no questions, no BS" that's so hard to understand? This is the situation in every other industrialized country. It's the US that's the insane outlier.

(The cost of health care means that it has to be paid for by progressive taxes. That's just economic reality, even in Japan where costs are much lower. People who object to those progressive taxes want poor (and middle class) people to die.)

2. Recent reductions in US life expectancy. That's the opioid epidemic*. In Japan, they don't give out opioids like candy, and they don't have an epidemic. I had excruciating acute lower back pain. Worse than any broken bone I'd ever had. I got physical therapy and an NSAID. In the US, I'd be an addict or dead. The US opioid epidemic has nothing to do with Obamacare, it's about MDs prescribing too many opioids. The number of patients still on opioids a year later is directly proportional to the amount of opioids prescribed. By.The.Physician. (Look it up.)

*: Which is largely a problem of reasonably well-off white folks. (Really, it is. Look it up.) Most of whom had insurance before Obamacare. (My understanding is that docs actually do understand that opioids are a problem and that some folks come looking for opioid prescriptions, so they largely don't prescribe opioids to poor and minority patients. But they do try to treat the pain their white patients suffer from.)

Whatever. Obamacare is a kludge and needs fixing. But it gets us closer to the "everyone has full access to affordable and good medical care with no questions, no BS" ideal that every other industrialized country achieves.

Dinah said...

I have no real answers here. I don't think our current system works, it's terribly expensive and our people don't live as long as in other countries. I think some of the people here are happy some of the time with their healthcare, and that may be true elsewhere as well. We have nationalized education: everyone has the option for public schools, some are better than others (and it may have more to do with factors aside from the quality of the teachers and the state of the equipment). If you don't like what's offered, you can move or pay for private schools. Or go to public schools and supplement them with paid tutoring/educational experiences. Even when the schools are awful, most Americans seem to learn to read and do math well enough to function, and some thrive even in lousy systems while others fail in the best of systems (personal note: I went to a public high school with 4,300 students -over 5,000, it's been written up in the New York Times for how lousy it was). I think we should offer a basic level of health care to everyone.

David,
Thanks for sharing the Japanese experience. And thanks for noticing our hiatus.

I do think it's worth looking at what other countries do, and why our costs are so much higher. I also realize that one of our issues is that we have such diversity with our people and our lifestyle choices. Some of the countries that we look to as ideals with lower costs, longer lifespans, have smaller populations, and more homogeneous populations -- this may well make the delivery of all types of services easier, and may effect outcomes more than the actual health care system. If we got rid of car accidents, gun deaths, and overdose deaths -- all of which may well disproportionately affect the young -- our lifespan numbers would be longer.

therapyfirst said...

"Recent reductions in US life expectancy. That's the opioid epidemic*.--*: Which is largely a problem of reasonably well-off white folks. (Really, it is. Look it up.) Most of whom had insurance before Obamacare. (My understanding is that docs actually do understand that opioids are a problem and that some folks come looking for opioid prescriptions, so they largely don't prescribe opioids to poor and minority patients. But they do try to treat the pain their white patients suffer from.)"

Sorry, that is just flagrant deflection to me. Yeah, the opiate abuse issue is PART of the reason, but not THE reason. As a practicing psychiatrist, I hear patients not only tell me they are compromising on accessing mental health services because of deductibles, but also somatic ones as well, and some even saying near word for word "well, if I have to weigh paying for cancer treatment, that could be a thought..."

It is nothing less than both astounding as well as what I see as insensitive indifference that people who can access care with what figuratively and literally amounts to minimal cost almost dismiss hearing the stories of those forced to have to stall getting care because of what really are astronomical expenses for paying for one's own health insurance of late.

And I am offended by that overgeneralization that opiate abuse is just a more well off caucasian problem. While this country still has more white people as a majority, opiate abuse is affecting Black, Hispanic, and other populations as well, maybe not to the percentage of whites, but, these are all AMERICAN people none the less. But, I sense identity politics at hand, hmmm?

Perhaps look into the growing abuse by teenagers of prescription drugs, noteably opiates and stimulants, and tell me it's only white teens doing this.

I work the front lines of this problem, don' try to manipulate this into what comes across as a partisan narrative, even if not Democrat, other country's liberal and progressive agendas.

Morbidity and mortality is rising in this country, and legislative control is a sizeable factor to it, and that should bother every single physician who genuinely cares about health care for everyone, not just partisan pals!

Laws are about positively and responsibly impacting on the sizeable majority of people, not a select few who can be manipulated into supporting a political agenda. This polarization and marginalizing of people is just hideous to endure, both parties are equally and pathetically guilty of it, and it is time for adults who are mature, educated, and responsible to stand up to this petty, destructive, self serving agenda. If people really think socialized medicine is going to be an improvement to what we have had until the last 6 years, enjoy what one seeks.

There will be consequences, I can say without hesitation count on it!

I have quoted Ayn Rand's writing about it from "Atlas Shrugged", paraphrasing the point "note the physician who resents being controlled and manipulated by outside forces, but even more so beware the one who does not care".

Hey, just my opinion, but one of over 25 years in the trenches...

Joel Hassman, MD

David J. Littleboy said...

"If people really think socialized medicine is going to be an improvement to what we have had until the last 6 years, enjoy what one seeks."

Up to six years ago, we had pre-existing conditions, yearly and lifetime limits, medical bankruptcies, recission (you lost your policy if you got sick), and vast numbers of people with no health insurance at all. All of these are things that don't exist in any other industrialized country.

What's so hard to understand about these _facts_ about the pre-Obamacare US system?

(I suspect that your experience is that previously what you saw was patients with "Cadillac" policies though their employers. Now you're seeing people who chose less than the most expensive choice through Obamacare. Sure, I'd like Obamacare to be more generous (better polices, more subsidies), but it doesn't sound like you're going to be supporting that...)

By the way, the life expectancy question is complicated. Suffice to say, the situation isn't what you've been claiming.

http://andrewgelman.com/2016/12/17/calm-american-life-expectancy-isnt-falling/

http://andrewgelman.com/2017/03/23/mortality-rate-trends-age-ethnicity-sex-state/

Ron Liebermann said...

This article, in my view, is beating around the bush. The real issue is how much health care should be made available. Most people use 80% of their care in the last years of their life. Thus, we see a lot of unnecessary procedures being performed on the elderly; for example, cancer treatment for those who are in their 90's.

The only cost-effective solution is to ration health care. Heart surgery and joint replacement should not be covered by Medicare. In fact, Medicare should be means-tested so that elderly patients pay for their own treatment; not the taxpayer. It doesn't matter if life expectancy goes down, in fact it should. We can't afford tens of millions of old people just sitting around.

therapyfirst said...

Per Ron L's comment above, all I can say is as long as a sizeable percentage of Americans expect and demand a full court press for terminal illness that is not treatable outside respectful efforts to maintain quality of life that is reasonable and fair, then we will have costs that reflect such reckless time and efforts.

People can come here and rant with their random chance exceptions that allegedly show the status quo should stay as is, but, then these same folks need to realize when they later complain they are impacted by rising costs of their own health care expenditures, well, what goes around comes around, hmm?

I do not fully agree with the second paragraph to Mr L's comment though, just reflexively saying we should fully expect to ration health care is not only foolish but dangerous as an outright expectation. It is not about rationing, but being rationale. Not a play on words, but simple reality. Politicians fully expect their constituents to play by separate rules and limits, and that in and of itself is why one does not reflexively keep these cretin politicians in office.

It is a complicated equation how to maximize making health care responsible, effective, and accountable, and you start by defining who are the players who make the rules and are impacted by the decisions. Politicians are not in the top of the list of players, the top are the providers and patients.

Hmm, who have never been asked for their opinions and concerns when these hideous legislative assaults are crafted and then forced on them, eh? So, this is what is representation in our country since 2009?

Oh, and also NOT at the top are the AMA, APA, and other organizations who have shown they do not represent their members, even the AARP. I'll say it once again, take the F-O-R out of profit in health care, and you might see outcomes genuinely not only improve, but be maintained. But, we don't really practice the concepts of sacrifice, responsibility, and accountability these last what, 20 years or more in health care?!

Again, just my opinion, of these last 25 plus years as a provider...

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phann son said...

I have no real answers here.

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